Healing Hurt People (HHP): A Public Health Approach to Managing the Disease of Violence

Transcription

1 Healing Hurt People (HHP): A Public Health Approach to Managing the Disease of Violence Co-Presenters Dr. Lori Morgan, M.D., MBA, Chief Administrative Officer Legacy Emanuel Medical Center, Vice President Legacy Health Dr. Jennifer Creedon, PGY-3 Psychiatry Resident, OHSU Tasha Wheatt-Delancy, MSW, Clinical Director Garlington- Cascadia Alisha Moreland, M.D. A partnership between Cascadia Behavioral Health, Legacy Emanuel Hospital & CareOregon

2 GOALS & OBJECTIVES Describe the neurobiology of violence Demonstrate the role that community hospital-based violence intervention programs (like Healing Hurt People ) play in preventing retaliatory violence & re-injury in a community Explore breaking the cycle of violence through timely interventions golden moments & coordinated partnerships

3 Dr. Creedon NEUROBIOLOGY OF VIOLENCE

4 NEUROBIOLOGY OF VIOLENCE Acts of violence account for an ~ 1.43 million deaths worldwide annually Violence occurs in many contexts individual acts of aggression make up the majority It is postulated that repetitive acts of violence & aggression are grounded in an underlying neurobiological susceptibility

5 Area of focus of HHP

6 NEUROBIOLOGY OF VIOLENCE Failure of top-down control systems in the prefrontal cortex to modulate aggressive acts that are triggered by anger provoking stimuli An imbalance between prefrontal regulatory influences & hyper-responsivity of the amygdala & other limbic regions

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8 NEUROANATOMY OF AGGRESSION & VIOLENCE Frontal lobes (orbitofrontal cortices) have a critical role in social cognition & impulse control Limbic structures (amygdalae) are responsible for basic emotion & drive-related behavior Structural & functional neuroimaging studies steadily add new data to establish these affiliations with more certainty

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10 APPROACHES TO THE TREATMENT OF VIOLENCE BASED ON THE NEUROBIOLOGICAL FRAME Pharmacological interventions Mood stabilizers - dampen limbic irritability Selective serotonin reuptake inhibitors (SSRIs)-may enhance top-down control OR Psychosocial Interventions - to develop alternative coping skills and reinforce reflective delay hence, Healing Hurt People (HHP)

11 HEALING HURT PEOPLE-PORTLAND VIOLENCE AS HEALTH CONCERN Dr. Moreland

12 THE SOCIAL CONTEXT OF VIOLENCE According to the Centers for Disease Control Reports Homicide accounted for 18,753 deaths in 2006 (18, 124 in 2005) Fifteen youth per day were killed in the United States in 2005 Homicide is the 2 nd leading cause of death in people years of age & 3 rd in ages Homicide is the #1 cause of death in African-Americans aged & #2 amongst Hispanics Fatalities from assaults represent the tip of the iceberg; non fatal injuries are believed to outnumber fatal injuries on the order of 100:1 As a result of tremendous societal affects of violent injury, violence prevention is considered a fundamental goal at the national level

13 Violence as health concern In 1996, the American Academy of Pediatrics (AAP) published a report pointing out that, while it has been routine to treat victims of child abuse, suicide attempts, and sexual assault via multidisciplinary care protocols no such care guidelines exist that address the unique needs of violently injured adolescents

14 Violence Treatment Mandate In 1998 the U.S Department of Justice s Office for Victims of Crime took the next step by recommending that hospital-based counseling and prevention programs be established in communities grappling with gang violence

15 HEALING HURT PEOPLE (HHP) HHP is a trauma-informed community-focused, hospital-based violence intervention program designed to reduce emergency room & hospital recidivism, re-injury, retaliation, PTSD & promote healing among individual males of color (ages 10-25) that have suffered from a penetrating trauma HHP is a part of the National Network of Hospital-Based Violence Intervention Programs (NNHVIP)

16 Care that is grounded in and directed by a thorough understanding of the neurological, biological, psychological and social effects of trauma and violence on humans and is informed by knowledge of the prevalence of these experiences in persons who receive mental health services. (NASMHPD, 2004)

17 HHP Strives to shift the way that health care addresses the needs of young victims of violence From a criminal based approach PUBLIC HEALTH FOCUS (multidisciplinary approach with a psycho-educational base)

18 Hospital-Based Violence Intervention Programs (HVIP) Successful models across the country: Oakland, San Francisco, Milwaukee, Philadelphia, Baltimore, Chicago, Indianapolis & Boston Running conviction of HVIP: Violence is preventable & Emergency Depts have a unique opportunity for a teachable - golden moment & meaningful intervention

19 Fidelity of the HHP model is defined by 3 principles 1. Golden Moment Engagement 2. In Hospital Engagement 3. Post-Discharge Follow Up

20 GOLDEN-TEACHABLE MOMENT Instance where injured victims are most poised & ripe for change Injured victims are lying in the trauma bay/surgical suite/icu & they are afraid. Studies suggest that it is at this point, that a decision to change is most likely to be made The HHP model seizes this moment & via motivational interviewing techniques, help facilitate a decision to do something different (to heal & not retaliate)

21 HVIP/HHP HVIP s were developed to promote positive alternatives to violence. HVIP s in other locations have powerfully demonstrated their ability to: Reduce hospital & E.R. recidivism (reducing health care costs) Reduce retaliation Reduce re-injury Reduce arrest

22 Why intervene at the hospital? 44% of young people hospitalized for violence return with another violent injury within 5 years 20% of them eventually die by violence

23 It Works 98% of clients remain re-injury free Participants are 70% LESS likely to be arrested within 6 months of injury than peers Becker, Calhoun et al 2004

24 Milwaukee Study Project Ujima, Milwaukee Emergency Department 200 pts, age % return post 1 year after hospital based intervention program involvement No control group M. Melzer-lange et al 2001

25 Chicago Study Chicago ED 12 month evaluation Treatment Group 8.1% Control group 20.3% Zun et. al. (Chicago, IL) Reduction in re-injury rate Zun et al 2006

26 Repeat Victims of Violence: Baltimore VIP Report of a Large Concurrent Case-Control Study Arch Surg. 2000; 135: Carnell Cooper, MD; Dawn Eslinger, MS; Denis Nash,PhD, MPH; Jalal Al Zawahri, MD, Paul Stolley, MD, MPH

27 Hospital-based Interventions Work! Age 18 Treatment (intervention): 250 violently injured youth Control group (non-intervention): 200 non-violently injured, matched for age & gender Previous hospitalization Blind randomization 3 year follow up FINDINGS Cooper et. al. (Baltimore, MD) Hospital based interventions do work Patients who were not involved in intervention were significantly more likely to be arrested for a violent crime, convicted of a violent crime, involved in repeat violent criminal activity

28 Healing Hurt People Flow Chart Injured victim: (stabbed or shot, age 10-25, male of color) Hospital ED/ Trauma Center Admitted or Discharged Emanuel s SW between the hours of 8AM-12 midnight & Chaplain between the hours of 12 midnight to 8AM Identify/Assess/Refer to HHP within (1-3.5 hours) of entering the ED or trauma bay HHP IPC Engages Client HHP PIS Engages Family - Provides basic psychoeducation - Assesses safety - Introduces HHP program Client Enrolls in HHP Contact HHP PIS/IPC Case Review Assessment Case Mgmt/ Navigation Mentoring SELF Groups Family Groups

29 Dr. Morgan HOSPITAL ENGAGEMENT

30 LEGACY EMANUEL: OUR COMMUNITY HOSPITAL BASED PARTNER FOR HHP

31 Legacy Emanuel Trauma Volumes 3,000 2,695 2,767 2,681 2,666 2,000 1,

32 LEMC Patient Demographics (2011) 22% between % male 60% African-American 40% Hispanic/Latino

33 Mechanism of Injury 2011 Stabbing: 109 Blunt: 2,409 Penetrating: 185 Firearms: 76 Other: 14 Penetrating Other Blunt Stabbing Firearms

34 Days Length of Stay = Opportunity for engagement in hospital Average LOS (days) 4.8 ISS 1-8 (Mild) ISS 9-15 (Moderate) ISS (Severe) ISS > 24 (Severe/Fatal) 8 17

35 FROM GOLDEN MOMENT TO POST DISCHARGE FOLLOW UP Tasha, MSW

36 Healing Hurt People (HHP) Origins - No psychosocial standard of care for violently injured patient Theory of Practice: Teachable/Golden moment Evidence of the effectiveness of health care-based interventions which utilize the teachable moment theory Trauma Theory Pervades all aspects of intervention

37 Healing Hurt People: An Emergency Medicinebased Intervention Strategy Trauma-informed: Recognizes the suffering & pain that patients have experienced over the course of their lives Acknowledges that trauma feeds the cycle of violence Youth of color are particularly impacted by the intersection of trauma & oppression Goals: Identify & treat trauma-related symptoms Decrease re-injury Decrease involvement with criminal justice system Develop a Best Practice for health care

38 Mentoring Peer Intervention Specialist s role: Establishes credibility with client Establishes trust with client Helps resist community pressure to retaliate Helps envision positive & a safe future

39 Assessment Mental Health PTSD (Foa, PSS-SR) Depression (Zung) Exposure to Violence Community violence Adverse childhood experiences Needs Assessment I.D., education, job training, criminal justice & substance misuse Assets Skills, interests & social supports Goals Career trajectories, employment & education

40 Case Management/Navigation Injury Prevention Coordinator Victims of Crime Assistance/Compensation Health insurance Identification Follow-up medical care Substance abuse treatment Mental health services Academic support Job training/vocational programs Housing assistance

41 S.E.L.F. Psychoeducation Groups Safety 10-week curriculum 7-10 clients Non-linear Provides cognitive framework for change Future Emotion Provides social support Loss

42 Intersection of Trauma & Oppression (Hardy et al) Devaluation Interruption of Cultural Community COMPLEX TRAUMA Anger Loss

43 HHP: Breaking the Cycle of Violence ASD/PTSD H H P Discharged to Street Trauma Self Medicate/ Get Weapon Treated in Hospital Injury/ Re-Injury/ Retaliation Death Jail Youth Shot/ Stabbed / Assaulted

44 HHP CONTACT HHP launches June 2013! Please contact Alisha Moreland, Alisha.Moreland@cascadiabhc.org or visit our website at for more details or to get involved.

45 Acknowledgements Dr. Lori Morgan- Chief Administrative Officer at Legacy Emanuel Administrative Team at Legacy Emanuel Dr. Maggie Bennington-Davis-Chief Medical and Operating Officer Cascadia Behavioral Health Derald Walker-Chief Executive Officer at Cascadia Behavioral Health Dr. Jonathan Betlinski, OHSU Public Psychiatry Dr. John Rich, Healing Hurt People Philadelphia Dr. Ted Corbin, Healing Hurt People Philadelphia CareOregon Sharon-Gary Smith, Executive Director of Mackenzie River Gathering Tasha Wheatt-Delancy, Director of Cascadia Garlington Deena Pierott, Diversity Cascadia Behavioral Health Dr. James Mason, Executive Director of Culturally Competent Caregiving, Providence Health-Portland Jennifer Creedon, PGY-3, OHSU Psychiatry Jaclyn Gadbois, 4 th year medical student, OHSU